Eastbourne District General Hospital
Requires improvement

Reports

Inspection carried out on 4, 5, 6 October 2016

During an inspection to make sure that the improvements required had been made

We inspected Eastbourne Hospital as part of the East Sussex Healthcare NHS Trust inspection on 4,5 and 6 October 2016. The trust had been previously inspected in September 2014 and March 2015. On both inspections we identified serious concerns and gave the hospital an overall rating of inadequate. The trust was rated inadequate overall because the two location reports and the concerns that we identified across the trust relating to culture and governance. A Quality Summit which included all key stakeholder organisations was held in September 2015 and, following that meeting, I recommended that the trust be placed into ‘Special Measures’. This meant that the trust was subject to additional scrutiny and support from the local clinical commissioning groups and NHSI who provided an improvement director to advise and to monitor the implementation of action plans to address the shortcomings identified. The commission also maintained a heightened programme of engagement and monitoring of data and concerns raised directly with us.

This inspection was specifically designed to test the requirement for the continued application of special measures at the trust. Prior to inspection we risk assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment led us to include six acute hospital services (emergency care, surgery, maternity and gynaecology, children and young people, end of life care and outpatients) in our inspection. The two other acute hospital services (medicine and critical care) and community services were not inspected as they had indicated good performance at previous inspections and our information review suggested that this had been sustained.

We did consider how medical services and the high number of medical patients impacted on patient flow and whether this affected other core services. We also visited medical wards as part of the review of end of life care.

We did not inspect community services as part of this inspection as they were currently rated ‘good’ overall. We did consider where new initiatives developed by the community services impacted upon the work of the two acute hospitals.

Following this inspection we have re-rated the services inspected. For other services we have maintained ratings from previous inspections. We have aggregated the ratings to provide an overall rating for the trust of requires improvement. Caring was rated as good, whilst safe, effective, responsive and well-led are all rated as requires improvement. This constitutes a significant improvement from the previous rating of inadequate.

.Our key findings were as follows: -

SAFE

The incident reporting culture had been significantly improved.

We saw clear evidence of learning from a Never Event with robust investigation and embedded changes to practice across the hospital.

Staff understanding of duty of candour had improved.

Infection control oversight had been significantly strengthened and hand hygiene practice was largely compliant.

We were able to see fledgling improvements in the provision of services trustwide with clear indicators of positive changes from data provided by the trust and from national data we hold at CQC about the trust.

Daily ‘Safety Huddles’ were being rolled out across the hospital. These encouraged the wider multidisciplinary team to share concerns and consider ways to improve the care of patients.

Where compliance with VTE risk assessment and prevention had been a concern in our previous inspection report, there was now evidence of high rates of compliance with 95% of patients having a properly completed VTE risk assessment in July 2016.

Safeguarding vulnerable adults and children was given sufficient priority.

Medicines management processes had been significantly improved.

The transfer of patients from ambulance to the emergency department was subject to delay and not being monitored.

There was a significant backlog in the reporting of x-ray examinations.

Record keeping was not consistent across the trust notably in the documentation of risk assessments within the emergency department and full completion of risk assessments in paediatric services.

Where electronic recording and escalation of observations had been introduced this had demonstrably improved the outcomes for patients.

Staff recruitment continued to be problematic with high levels of bank and agency use in some areas. There were departments such as the emergency department where the staffing arrangements were not in line with the national recommendations.

EFFECTIVE

Pain was managed well with new initiatives in the care of children and young people and better recording of pain scores across the hospital.

Stroke services had been consolidated at the Eastbourne site. A recent report issued by the Stroke Association in November 2016 showed that the hospital was providing good access to stroke services.

End of life care and emergency departments were not meeting national audit standards in some areas.

The assessment of mental capacity by staff remained inconsistent across the trust.

The wishes of patients about the upper limit of treatment when on an end of life care pathway was not always recorded. Staff had not always discussed the 'ceiling of care with patients or their families.

There were no services now rated as inadequate

Policies were largely up to date and referenced by best practice, with the exception of maternity services.

Surgery services were no longer an outlier for clinical outcomes.

Auditing programmes were more developed than on previous inspection visits but further work was needed to ensure that the full cycle of data collation being used to drive improvements needed further embedding.

CARING

All services inspected were rated as good for caring.

Data and our observations confirmed the very positive feedback received from patients with respect to the caring nature of staff.

Staff treated patients with dignity, respect and kindness. Patients felt supported and said staff cared about them. Patients and staff worked together to plan care and there was shared decision-making about care and treatment

The trust’s Friends and Family Test performance (% recommended) was generally better than the England average between July 2015 and June 2016. In the latest period, July 2016 trust performance was 97.9 % compared to an England average of 95.4%. This was an improvement on the performance in the FFT in August 2014, when the score was 67% trust wide.

RESPONSIVE

The emergency department indicated a deteriorating performance against access standards.

The trust was not maintaining the delivery of treatment to patients within 18 weeks of referral from GP's or within 62 days for patients referred onto a cancer pathway.

Patient flow through the hospital was challenged leading to patients being cared for in suboptimal clinical areas.

A Frailty Nurse Specialist team had been set up to work across the acute hospitals and community services to reduce the number of unnecessary admission (particularly from care homes) and to support patients who were best cared for in the community.

Patients on an end of life care pathway did not have access to a rapid discharge service.

The outpatients service was no longer rated as inadequate with significant improvements to the call centre.

The hospital staff tried to ensure that the individual needs and preferences of patients were met. Our previous report from September 2014 talked about staffing shortages and a culture that led to task focussed nursing care and a lack of consideration of individual needs. This was not something we observed on this inspection visit.

The trust was very responsive to meeting the complex needs of patients notably those living with dementia or learning disabilities.

.Appropriately trained staff were not available to support children who were particularly anxious or in pain through play

Response times to complaints had improved significantly since April 2016. We saw evidence of appropriate responses to complaints, and learning from complaints and concerns. The trust had improved the way they responded to complaints as well as the response times.

WELL LED

No services were rated as inadequate for leadership.

The senior leadership was now sighted on operational and strategic issues and had clear and well considered plans for service improvement.

Staff told us that the executive team were much more visible around the hospital than they had been prior to the appointment of the new chair in January 2016 and new chief executive in April 2016.

Nursing staff also talked to us about the Director of Nursing (DoN) who was felt to be a consistent and steadying influence as the trust went through a period of significant change. Nurses said they trusted the DoN and felt she was ever present, approachable and understood the challenges at ward level.

The organisational culture had transformed since our last inspection. Staff were largely positive, well engaged and felt valued by the organisation. However, there were areas where staff were still feeling daunted by the changes and where morale was low. This was particularly the case with medical records and some administrative staff where the systems they worked with and, in some cases, their place of work had changed.

Governance had been significantly strengthened in terms of structure and the quality of board papers and data. This had led to a strong sense of accountability within the trust.

The senior team remains relatively new in constitution and some elements of governance and performance management have only recently been introduced

The trust was yet to complete the transition to a new operational structure.

At service levels our inspection identified some weaknesses in the management of risk and mortality.

Innovation was now encouraged and we saw several areas where staff had been encouraged and supported to introduce changes to bring about improvements in quality and safety. Staff felt more engaged in developing the service and were allowed more involvement in how services were provided.

We saw several areas of outstanding practice including:

Following the project lead midwife’s maternity review, the trust had introduced a programme of project groups related to maternity. These included the pilot scheme of a new homebirth and triage role for community midwives, and a perinatal mental health specialist midwife role.

A consultant orthopaedic surgeon had written a national guide for the Royal College of Surgeons on avoiding unconscious bias which was published in August. The guide focused on overcoming the unconscious opinions that everyone forms about people when they first meet them and offered advice to get beyond this. This national guidance referenced the trust’s Anti-bullying Policy in the Doctors’ Clinical Handbook and highlighted the progress and work made within the trust to address perceptions of bullying and harassment.

We saw an example of best practice for care provided to dental patients with special needs or learning disabilities. A multidisciplinary planning meeting was conducted in advance of the attendance. The appointment was used to provide one stop care including taking bloods, scans and giving the patient a haircut to minimise distress to the patient. There were a variety of options provided for location; aspects of care could be initiated in different locations such as properly supported sedation in the patient’s home and anaesthesia in the car park or in the hospital depending on the need.

A dedicated multidisciplinary team had established a five-year plan to establish an innovative rehabilitation care plan as part of an out of hospitals services transformation programme. This programme included staff from multiple specialties and enabled ED staff to work with colleagues from across the trust and in the community to develop future services, including an ambulatory rehabilitation unit and a rapid access care service. The programme planned to introduce nurse practitioner roles for frailty, crisis response and proactive care who would provide an integrated rehabilitation service alongside hospital and community-based specialists. This programme would significantly improve working links between the trust’s hospitals and local authority social care services and enable rehabilitation services to be provided more responsively to avoid the need for hospital admissions. There was significant support and infrastructure for staff to develop this programme and they had been invited to present their plans and work so far at a national Health and Social Care Awards ceremony.

Patients on a cancer pathway had a dedicated booking team in the booking centre. All referrals were received electronically and an email was sent to the GP to indicate it had been received. The booking team escalated concerns about appointments to service managers. Weekly cancer patient tracking list meetings provided clinical oversight of patients on cancer pathways.

The paediatric team had introduced a ‘consultant of the week’ system whereby a designated consultant answered enquiries from local GPs about sick children in their care. This recent initiative had reduced the number of admissions because GPs had a specific point of contact and could be supported to care for the child in the community, where practical.

An entrepreneur programme was being established that focused on the reduction of ambulance handover delays.

There were good initiatives being developed and encouraged to meet people’s individual needs. The hospital’s League of Friends team had knitted comfort bands for patients, which helped them stop picking at intravenous lines. A ‘distraction box’ was also available to help provide stimulation for patients with dementia and reduce their anxiety in an unfamiliar environment. A nurse had developed a number of resources to help provide emotional support to parents who lost a child to sudden infant death syndrome.

A member of the maintenance team had given up his own time to paint a mural on the wall of the recently decorated ultrasound unit to soften the environment for young patients.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must :

Ensure that consultant cover meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.

Ensure that play specialist staff are employed to lead and develop play services in all areas where children are cared for.

In addition the trust should:

Review all maternity policies and procedures that are outside their review date and take action to ensure all policies reflect current national and evidence-based guidance.

The hospital should discuss and record ceilings of care for patients who have a DNACPR.

The trust should have a defined regular audit programme for the end of life care service.

The trust should provide for the specialist palliative care team at Eastbourne District general Hospital weekly multidisciplinary meetings to discuss all aspects of patient’s medical and palliative care needs.

The trust should record evidence of discussion of an end of life care patient’s spiritual needs.

The trust should implement a formal feedback process to capture bereaved relatives views of delivery of care.

The trust should ensure that all staff received regular mandatory training for end of life care.

The trust should provide a formal referral criterion for the specialist care team for staff to follow.

The trust should define and streamline their end of life care service to ensure staff are clear of their roles and who to contact.

Develop a rapid discharge process for end of life care patients to be discharged to their preferred place of death.

Extend the Palliative care team service to provide support and advice over the full seven days. As the hospital did not currently have this provision, some patients did not have access to specialist palliative support, for care in the last days of life in all cases.

Work towards meeting the requirements of the key performance indicators of the National Care of the Dying Audit (NCDAH) 2016.

Develop and implement a programme of regular audits for end of life care.

The trust should ensure audits of infection control practices in ED including hand hygiene are used to improve practice.

Investigate and reduce the mixed sex breaches on surgical wards at EDGH. The reason for these should be documented in all cases.

Continue to consider ways to improve staff recruitment and retention such that it meets the national recommended levels.

Work with local stakeholders to address the delays to patient pathways and continue to progress towards meeting their referral to treatment time targets.

The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.

Play services should be developed and a play specialist employed.

The trust should ensure hazardous waste management and disposal practices in the ED meet national control of substances hazardous to health guidance.

The trust should ensure nurse to patient ratios in the ED are managed in relation to the individual needs of patients based on acuity.

The trust should ensure that RTT is met in accordance with national standards.

The trust should ensure that standard for a patient receiving their first treatment within 62 days of an urgent GP referral is met.

The diagnostic imaging department should ensure they are reporting incidents in line with legislation and demonstrate following their own policy.

The diagnostic department should ensure all policies and procedures are up to date.

The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.

The diagnostic imaging department should monitor their waiting and reporting times.

The diagnostic imaging department should ensure staff attend mandatory training in line with the trusts target.

The children's service should develop clear criteria for the transfer of patients by private car between sites.

The children's service should ensure that children are not transferred to the Conquest Hospital late at night, through timely decision making and effective planning of the transfer.

The children's service should ensure that outpatients appointments are not subject to cancellation and delays,.

Professor Sir Mike Richards

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During an inspection to make sure that the improvements required had been made

We inspected Eastbourne Hospital as part of the East Sussex Healthcare NHS Trust inspection on 24, 25 and 26 March 2015 and 10 April to follow up on serious concerns at our previous that we had identified at our previous comprehensive inspection in September 2014.

The trust serves a population of around 525,000 patients from across the East Sussex area. There are approximately 700 beds and 7,200 staff. The trust provides a full range of DGH services, although not all services are available at both acute hospital sites. The trust has links to Brighton, Tunbridge Wells and London for some tertiary services.

We found that whilst some fledgling improvements had been made to services provided at the hospital they remained inadequate for safety and leadership and required further improvements for effectiveness and responsive with particular concerns about the provision of services in Outpatients and Surgery .

We found that caring was largely good across the trust. However, the NHS Staff Survey 2014 demonstrated very low staff morale and we found high staff sickness levels at the trust. The

East Sussex Healthcare NHS Trust (ESHT) provides acute hospital and community health services for people living in East Sussex and the surrounding areas. The trust serves a population of 525,000 people and is one of the largest organisations in the county. Acute hospital services are provided from Conquest Hospital in Hastings and Eastbourne District General Hospital, both of which have Emergency Departments. Acute children’s services and maternity services are provided at the Conquest Hospital and a midwifery-led birthing service and short-stay children’s assessment units are also provided at Eastbourne District General Hospital.

The trust also provides a minor injury unit service from Crowborough War Memorial Hospital, Lewes Victoria Hospital and Uckfield Community Hospital. A midwifery-led birthing service along with outpatient, rehabilitation and intermediate care services are provided at Crowborough War Memorial Hospital. At both Bexhill Hospital and Uckfield Community Hospital the trust provides outpatients, day surgery, rehabilitation and intermediate care services. Outpatient services and inpatient intermediate care services are provided at Lewes Victoria Hospital and Rye, Winchelsea and District Memorial Hospital. At Firwood House the trust jointly provides, with Adult Social Care, inpatient intermediate care services.

Trust community staff also provide care in patients’ own homes and from a number of clinics and health centres, GP surgeries and schools.

The trust employs almost 7,000 staff and has 820 inpatient beds across its acute and community sites. The trust serves the population of East Sussex which numbers 525,000.

We carried out this unannounced focussed inspection in March 2015. We analysed data we already held about the trust to inform our inspection planning. Teams, which included CQC inspectors and clinical experts, visited the two acute hospitals along with the Crowborough Birthing Centre and reviewed four of the eight core services that we usually inspect as part of our comprehensive inspection methodology. Service reviewed were maternity services, outpatient services, surgery and accident and emergency care; we reviewed these particular core services as in our comprehensive inspection in September 2014, we had identified serous concerns about the care and treatment provided. We spoke with staff of all grades, individually and in groups, who worked in these services. Staff from across the trust attended our drop in sessions on both sites.

In September 2014 we identified concerns about the provision of pharmacy services. We looked at this in our unannounced visits by a CQC pharmacist. As the issues identified are across the whole hospital (rather than within one core service), we have included our findings on pharmacy as a trust wide service in the provider report. A large number of people from the local community and staff had contacted CQC after the previous inspection report was published to tell us it was an accurate reflection of the way the trust provided services.

It is important to note that in the past two years the trust had been through a period of significant change with reconfiguration of some key services across both acute sites. The trust had followed guidance on both consultation and reconfiguration set out by the Secretary of State for Health. The consultation process was led by the local Clinical Commission Groups and has been assessed by an audit of its corporate governance. The assessment of this process by internal audit company provided assurance to the board and stakeholders that “Corporate governance, in relation to the maternity project specifically, considered to be executed to a high standard and in compliance with the selection of Good Governance Institute outcomes examined”. It also set out that “Structures and decision-making processes clearly set out and followed”. We were aware that the reconfiguration was not universally accepted as a positive change by some members of the public and some staff.

During this unannounced follow up inspection and in the preceding comprehensive inspection we reviewed clinical services as they are currently configured. Our remit does not include commenting on local decisions about the configuration of services. We have, where pertinent, considered the safety and effectiveness of the services post reconfiguration and whether the trust is responsive to individual and local needs.

Our key findings from the unannounced follow up inspection were as follows:

The trust board continues to say they recognise that staff engagement is an area of concern but the evidence we found suggests there is a void between the Board perception and the reality of working at the trust. At senior management and executive level the trust managers spoke entirely positively and said the majority of staff were ‘on board’, blaming just a few dissenters for the negative comments that we received.

We found the widespread disconnect between the trust board and its staff persisted. This did not appear to be acknowledged by the senior management team.

The NHS staff survey shows the trust below average for 23 of the 29 staff engagement measures and in the worst 20% for 18 of these.

We saw a culture where staff remained afraid to speak out or to share their concerns openly. We heard about detriment staff had suffered when they raised concerns about risks to patient safety.

Staff remained unconvinced of the benefit of incident reporting, and were therefore not reporting incidents or near misses to the trust. the trust was not able to benefit from any learning from these. this position had not improved.

We found that management of outpatients’ reconfiguration has led to service deterioration with long delays in the referral to treatment time in some specialities. We did, however that local managers had taken some steps that had resulted in an improved patient experience.

In surgery and OPD there was clear evidence of significant underreporting of incidents through the correct system. This related to high tolerance or thresholds in the surgical clinical unit and a management decision to prevent staff reporting OPD reception incidents through the proper channels.

We saw low staffing levels that impacted on the trusts ability to deliver efficient and effective care.

We remained concerned about medicines management and pharmacy services.

The trust was breaching the provision of single sex accommodation requirements frequently and regularly but not identifying or reporting these. Women and men were both accommodated overnight in the clinical decisions unit and had to walk past people of the opposite sex to use the lavatories and washing facilities.

The trust was sometimes failing to consider the impact of moving patients between wards and discharging patients through the night. We heard from one patients who told us that they were moved to a different ward in the middle of the night without being informed as they were sleeping.

The poor quality of health records and frequent lack of availability continued to pose a risk.

Storage and operational arrangements did not ensure that people's personal information remained confidential.

The referral to treatment times in a number of specialities continued to be significantly worse than expected when compared nationally.

Short notice cancellations of outpatient clinics continued to be a problem. Large numbers of appointments were cancelled at very short notice. In some cases, people arrived for the appointment unaware it had been cancelled.

We saw several areas where good practice was identified including:

The telephone triage system provided a high standard of information, guidance and support to women, without them necessarily needing to come into hospital.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Make sure the privacy and dignity of patients is upheld by avoiding same-sex breaches in the clinical decision unit (CDU) and other areas of the trust. Breaches of same-sex accommodation must be reported accurately.

Review the arrangements for protecting he privacy and dignity of patients attending the radiology department and the OPD.

Improve the management of medicines in the ED to promote patient safety.

Review occupational health and human resources support and resources in place for staff who are on long-term sick leave or who need support, to ensure the trust can meet its duty of care to its workforce.

Conduct a trust-wide review of staffing levels to ensure that patient acuity and turnover is taken into consideration.

Give serious consideration to how it is going to rebuild effective relationships with its staff, the public and other key stakeholders. This was a requirement following our inspection on September 2014 but we are not yet assured from the action plan and speaking with the lead executive officer that this has been addressed.

Create an organisational culture which is grounded in openness, where people feeling able to speak out without fear of reprisal. This was a requirement following our inspection on September 2014 but we are not yet assured that staff feel able to speak out without suffering detriment.

Undertake a root and branch review across the organisation to address the perceptions of a bullying culture, as required in our previous inspection report.

Review and improve the trust’s pharmacy service and management of medicines.

Review the reconfiguration of outpatients’ services to ensure that it meets the needs of those patients using the service.

Review the length of waiting time for outpatients’ appointments such that they meet the governments RTT waiting times.

Ensure that health records are available and that patient and staff data is confidentially managed.

Give full consideration to whether there have been any breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 5 (3)(d) Fit and proper persons: directors

In addition the trust should:

Ensure that staff fully and accurately complete documentation.

Ensure that fridges used for the storage of medicines are kept locked and are not accessible to people and that medicines are secured in lockable units. This is something that is required as part of Regulation 13 in relation to the management of medicines but it was considered that it would not be proportionate for that one finding to result in a judgement of a breach of the Regulation overall at the location.

Develop sustainable systems for the review and monitor compliance with national guidance on VTE risk assessments.

Develop sustainable systems for ensuring that emergency equipment is checked in accordance with trust policy and national guidance.

The trust should ensure that the room in the ED designated for the interview of patients presenting with mental health needs has a suitable design and layout to minimise the risk of avoidable harm and promote the safety of people using it.

The trust should review the number and skill mix of nurses on duty in the ED department to reflect NICE guidelines to ensure patients’ welfare and safety are promoted and their individual needs are met.

The trust should review the number of consultant EM doctors in the ED and how they are deployed to reflect the College of Emergency Medicine (CEM) recommendations.

The trust should improve the uptake of mandatory training amongst staff working in Urgent Care.

The trust should make sure there are enough competent staff working in Urgent Care to respond to a major incident.

The trust should review the arrangements for monitoring pain experienced by patients in the ED to make sure people have effective pain relief.

The trust should review their arrangements for assessing and recording the mental capacity of patients in the ED to demonstrate that care and treatment is delivered in patients’ best interests.

The trust should make arrangements to ensure contracted security staff have appropriate knowledge and skills to safely work with vulnerable patients with a range of physical and mental ill health needs.

The trust should review some areas of the environment in the ED with regard to the lack of visibility of patients in the children’s waiting area; the arrangements for supporting people’s privacy at the reception and triage bay and the suitability of the relatives’ room

The trust should review the provision of written information to other languages and formats so that it is accessible to people with language or other communication difficulties.

Subsequent to this inspection visit a warning notice served under Section 29a of the Health and Social Care Act 2008. This warning notice informed the trust that the Care Quality Commission had formed the view that the quality of health care provided by East Sussex Healthcare NHS Trust requires significant improvement:

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During a routine inspection

We inspected Eastbourne Hospital as part of the East Sussex Healthcare NHS Trust inspection on 4,5 and 6 October 2016. The trust had been previously inspected in September 2014 and March 2015. On both inspections we identified serious concerns and gave the hospital an overall rating of inadequate. The trust was rated inadequate overall because the two location reports and the concerns that we identified across the trust relating to culture and governance. A Quality Summit which included all key stakeholder organisations was held in September 2015 and, following that meeting, I recommended that the trust be placed into ‘Special Measures’. This meant that the trust was subject to additional scrutiny and support from the local clinical commissioning groups and NHSI who provided an improvement director to advise and to monitor the implementation of action plans to address the shortcomings identified. The commission also maintained a heightened programme of engagement and monitoring of data and concerns raised directly with us.

This inspection was specifically designed to test the requirement for the continued application of special measures at the trust. Prior to inspection we risk assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment led us to include six acute hospital services (emergency care, surgery, maternity and gynaecology, children and young people, end of life care and outpatients) in our inspection. The two other acute hospital services (medicine and critical care) and community services were not inspected as they had indicated good performance at previous inspections and our information review suggested that this had been sustained.

We did consider how medical services and the high number of medical patients impacted on patient flow and whether this affected other core services. We also visited medical wards as part of the review of end of life care.

We did not inspect community services as part of this inspection as they were currently rated ‘good’ overall. We did consider where new initiatives developed by the community services impacted upon the work of the two acute hospitals.

Following this inspection we have re-rated the services inspected. For other services we have maintained ratings from previous inspections. We have aggregated the ratings to provide an overall rating for the trust of requires improvement. Caring was rated as good, whilst safe, effective, responsive and well-led are all rated as requires improvement. This constitutes a significant improvement from the previous rating of inadequate.

.Our key findings were as follows: -

SAFE

The incident reporting culture had been significantly improved.

We saw clear evidence of learning from a Never Event with robust investigation and embedded changes to practice across the hospital.

Staff understanding of duty of candour had improved.

Infection control oversight had been significantly strengthened and hand hygiene practice was largely compliant.

We were able to see fledgling improvements in the provision of services trustwide with clear indicators of positive changes from data provided by the trust and from national data we hold at CQC about the trust.

Daily ‘Safety Huddles’ were being rolled out across the hospital. These encouraged the wider multidisciplinary team to share concerns and consider ways to improve the care of patients.

Where compliance with VTE risk assessment and prevention had been a concern in our previous inspection report, there was now evidence of high rates of compliance with 95% of patients having a properly completed VTE risk assessment in July 2016.

Safeguarding vulnerable adults and children was given sufficient priority.

Medicines management processes had been significantly improved.

The transfer of patients from ambulance to the emergency department was subject to delay and not being monitored.

There was a significant backlog in the reporting of x-ray examinations.

Record keeping was not consistent across the trust notably in the documentation of risk assessments within the emergency department and full completion of risk assessments in paediatric services.

Where electronic recording and escalation of observations had been introduced this had demonstrably improved the outcomes for patients.

Staff recruitment continued to be problematic with high levels of bank and agency use in some areas. There were departments such as the emergency department where the staffing arrangements were not in line with the national recommendations.

EFFECTIVE

Pain was managed well with new initiatives in the care of children and young people and better recording of pain scores across the hospital.

Stroke services had been consolidated at the Eastbourne site. A recent report issued by the Stroke Association in November 2016 showed that the hospital was providing good access to stroke services.

End of life care and emergency departments were not meeting national audit standards in some areas.

The assessment of mental capacity by staff remained inconsistent across the trust.

The wishes of patients about the upper limit of treatment when on an end of life care pathway was not always recorded. Staff had not always discussed the 'ceiling of care with patients or their families.

There were no services now rated as inadequate

Policies were largely up to date and referenced by best practice, with the exception of maternity services.

Surgery services were no longer an outlier for clinical outcomes.

Auditing programmes were more developed than on previous inspection visits but further work was needed to ensure that the full cycle of data collation being used to drive improvements needed further embedding.

CARING

All services inspected were rated as good for caring.

Data and our observations confirmed the very positive feedback received from patients with respect to the caring nature of staff.

Staff treated patients with dignity, respect and kindness. Patients felt supported and said staff cared about them. Patients and staff worked together to plan care and there was shared decision-making about care and treatment

The trust’s Friends and Family Test performance (% recommended) was generally better than the England average between July 2015 and June 2016. In the latest period, July 2016 trust performance was 97.9 % compared to an England average of 95.4%. This was an improvement on the performance in the FFT in August 2014, when the score was 67% trust wide.

RESPONSIVE

The emergency department indicated a deteriorating performance against access standards.

The trust was not maintaining the delivery of treatment to patients within 18 weeks of referral from GP's or within 62 days for patients referred onto a cancer pathway.

Patient flow through the hospital was challenged leading to patients being cared for in suboptimal clinical areas.

A Frailty Nurse Specialist team had been set up to work across the acute hospitals and community services to reduce the number of unnecessary admission (particularly from care homes) and to support patients who were best cared for in the community.

Patients on an end of life care pathway did not have access to a rapid discharge service.

The outpatients service was no longer rated as inadequate with significant improvements to the call centre.

The hospital staff tried to ensure that the individual needs and preferences of patients were met. Our previous report from September 2014 talked about staffing shortages and a culture that led to task focussed nursing care and a lack of consideration of individual needs. This was not something we observed on this inspection visit.

The trust was very responsive to meeting the complex needs of patients notably those living with dementia or learning disabilities.

.Appropriately trained staff were not available to support children who were particularly anxious or in pain through play

Response times to complaints had improved significantly since April 2016. We saw evidence of appropriate responses to complaints, and learning from complaints and concerns. The trust had improved the way they responded to complaints as well as the response times.

WELL LED

No services were rated as inadequate for leadership.

The senior leadership was now sighted on operational and strategic issues and had clear and well considered plans for service improvement.

Staff told us that the executive team were much more visible around the hospital than they had been prior to the appointment of the new chair in January 2016 and new chief executive in April 2016.

Nursing staff also talked to us about the Director of Nursing (DoN) who was felt to be a consistent and steadying influence as the trust went through a period of significant change. Nurses said they trusted the DoN and felt she was ever present, approachable and understood the challenges at ward level.

The organisational culture had transformed since our last inspection. Staff were largely positive, well engaged and felt valued by the organisation. However, there were areas where staff were still feeling daunted by the changes and where morale was low. This was particularly the case with medical records and some administrative staff where the systems they worked with and, in some cases, their place of work had changed.

Governance had been significantly strengthened in terms of structure and the quality of board papers and data. This had led to a strong sense of accountability within the trust.

The senior team remains relatively new in constitution and some elements of governance and performance management have only recently been introduced

The trust was yet to complete the transition to a new operational structure.

At service levels our inspection identified some weaknesses in the management of risk and mortality.

Innovation was now encouraged and we saw several areas where staff had been encouraged and supported to introduce changes to bring about improvements in quality and safety. Staff felt more engaged in developing the service and were allowed more involvement in how services were provided.

We saw several areas of outstanding practice including:

Following the project lead midwife’s maternity review, the trust had introduced a programme of project groups related to maternity. These included the pilot scheme of a new homebirth and triage role for community midwives, and a perinatal mental health specialist midwife role.

A consultant orthopaedic surgeon had written a national guide for the Royal College of Surgeons on avoiding unconscious bias which was published in August. The guide focused on overcoming the unconscious opinions that everyone forms about people when they first meet them and offered advice to get beyond this. This national guidance referenced the trust’s Anti-bullying Policy in the Doctors’ Clinical Handbook and highlighted the progress and work made within the trust to address perceptions of bullying and harassment.

We saw an example of best practice for care provided to dental patients with special needs or learning disabilities. A multidisciplinary planning meeting was conducted in advance of the attendance. The appointment was used to provide one stop care including taking bloods, scans and giving the patient a haircut to minimise distress to the patient. There were a variety of options provided for location; aspects of care could be initiated in different locations such as properly supported sedation in the patient’s home and anaesthesia in the car park or in the hospital depending on the need.

A dedicated multidisciplinary team had established a five-year plan to establish an innovative rehabilitation care plan as part of an out of hospitals services transformation programme. This programme included staff from multiple specialties and enabled ED staff to work with colleagues from across the trust and in the community to develop future services, including an ambulatory rehabilitation unit and a rapid access care service. The programme planned to introduce nurse practitioner roles for frailty, crisis response and proactive care who would provide an integrated rehabilitation service alongside hospital and community-based specialists. This programme would significantly improve working links between the trust’s hospitals and local authority social care services and enable rehabilitation services to be provided more responsively to avoid the need for hospital admissions. There was significant support and infrastructure for staff to develop this programme and they had been invited to present their plans and work so far at a national Health and Social Care Awards ceremony.

Patients on a cancer pathway had a dedicated booking team in the booking centre. All referrals were received electronically and an email was sent to the GP to indicate it had been received. The booking team escalated concerns about appointments to service managers. Weekly cancer patient tracking list meetings provided clinical oversight of patients on cancer pathways.

The paediatric team had introduced a ‘consultant of the week’ system whereby a designated consultant answered enquiries from local GPs about sick children in their care. This recent initiative had reduced the number of admissions because GPs had a specific point of contact and could be supported to care for the child in the community, where practical.

An entrepreneur programme was being established that focused on the reduction of ambulance handover delays.

There were good initiatives being developed and encouraged to meet people’s individual needs. The hospital’s League of Friends team had knitted comfort bands for patients, which helped them stop picking at intravenous lines. A ‘distraction box’ was also available to help provide stimulation for patients with dementia and reduce their anxiety in an unfamiliar environment. A nurse had developed a number of resources to help provide emotional support to parents who lost a child to sudden infant death syndrome.

A member of the maintenance team had given up his own time to paint a mural on the wall of the recently decorated ultrasound unit to soften the environment for young patients.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must :

Ensure that consultant cover meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.

Ensure that play specialist staff are employed to lead and develop play services in all areas where children are cared for.

In addition the trust should:

Review all maternity policies and procedures that are outside their review date and take action to ensure all policies reflect current national and evidence-based guidance.

The hospital should discuss and record ceilings of care for patients who have a DNACPR.

The trust should have a defined regular audit programme for the end of life care service.

The trust should provide for the specialist palliative care team at Eastbourne District general Hospital weekly multidisciplinary meetings to discuss all aspects of patient’s medical and palliative care needs.

The trust should record evidence of discussion of an end of life care patient’s spiritual needs.

The trust should implement a formal feedback process to capture bereaved relatives views of delivery of care.

The trust should ensure that all staff received regular mandatory training for end of life care.

The trust should provide a formal referral criterion for the specialist care team for staff to follow.

The trust should define and streamline their end of life care service to ensure staff are clear of their roles and who to contact.

Develop a rapid discharge process for end of life care patients to be discharged to their preferred place of death.

Extend the Palliative care team service to provide support and advice over the full seven days. As the hospital did not currently have this provision, some patients did not have access to specialist palliative support, for care in the last days of life in all cases.

Work towards meeting the requirements of the key performance indicators of the National Care of the Dying Audit (NCDAH) 2016.

Develop and implement a programme of regular audits for end of life care.

The trust should ensure audits of infection control practices in ED including hand hygiene are used to improve practice.

Investigate and reduce the mixed sex breaches on surgical wards at EDGH. The reason for these should be documented in all cases.

Continue to consider ways to improve staff recruitment and retention such that it meets the national recommended levels.

Work with local stakeholders to address the delays to patient pathways and continue to progress towards meeting their referral to treatment time targets.

The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.

Play services should be developed and a play specialist employed.

The trust should ensure hazardous waste management and disposal practices in the ED meet national control of substances hazardous to health guidance.

The trust should ensure nurse to patient ratios in the ED are managed in relation to the individual needs of patients based on acuity.

The trust should ensure that RTT is met in accordance with national standards.

The trust should ensure that standard for a patient receiving their first treatment within 62 days of an urgent GP referral is met.

The diagnostic imaging department should ensure they are reporting incidents in line with legislation and demonstrate following their own policy.

The diagnostic department should ensure all policies and procedures are up to date.

The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.

The diagnostic imaging department should monitor their waiting and reporting times.

The diagnostic imaging department should ensure staff attend mandatory training in line with the trusts target.

The children's service should develop clear criteria for the transfer of patients by private car between sites.

The children's service should ensure that children are not transferred to the Conquest Hospital late at night, through timely decision making and effective planning of the transfer.

The children's service should ensure that outpatients appointments are not subject to cancellation and delays,.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During a routine inspection

On the 7 May 2013 the East Sussex Healthcare NHS Trust (ESHT) completed the temporary reconfiguration of maternity and paediatric services. This had been undertaken as a result of an escalation in concerns regarding the overall safety of maternity provision within the acute hospitals.

The Care Quality Commission made plans to review the newly configured service, and allowed a month for the new service arrangements to embed. Prior to our planned visit we received information from a team of consultant paediatricians working at Eastbourne District General Hospital. They expressed concerns that the new arrangements for paediatrics across the Trust were now less safe than before. We met with the consultants on 18 June supported by a paediatric specialist. We listened to their concerns and said that we would give these due consideration in our planned inspection of these services.

When we visited the service at Eastbourne we were supported by a paediatric specialist, and a maternity specialist. We spoke with staff at all levels of the Trust to gain their views about the safety of the service. We looked at systems, and reviewed documentation. We spoke with parents, mothers and relatives of people using these services. From the feedback we received and records viewed we were satisfied that the Trust was providing a safe, effective, responsive, caring and well led maternity and paediatric service.

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During an inspection to make sure that the improvements required had been made

We met the trust Chair, Chief Executive and spoke with staff at all levels. We reviewed a range of documentary evidence. We found that systems were in place for the safe management of medication. Quality monitoring systems were embedded and effective in providing information about the operational quality of patient services across the trust.

Staff we met were welcoming and co-operative. At ward level they demonstrated awareness and commitment to the improvements around recording of patient care, and confirmed the monitoring systems in place. They told us they felt they were kept informed.

We saw that backlogs in the management of complaints and serious incidents had been addressed and processes implemented to minimise recurrence. Scrutiny through review groups and subcommittees provided assurance that emerging patterns or increased incidence in any area was discussed and investigated. Written and verbal evidence indicated the trust was proactive in identifying issues and seeking advice from external organisations or specialists to gain assurance around patient safety.

Programmes had been implemented for listening to staff and strategies for engaging with patients. We saw early analysis of patient feedback on some wards but it was unclear how this influenced service development. From discussion with staff it was clear that shared learning from safeguarding and incidents was undeveloped and discharge arrangements for patients varied between wards.

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During an inspection in response to concerns

The Care Quality Commission was notified by the trust of four serious untoward incidents that had occurred. We undertook a responsive review to ascertain any ongoing impact on people’s safety and to establish action taken by the trust in response to these incidents.

Five people who were using the service were spoken with and were asked for their views on their treatment, and the care provided in the maternity unit.

All feedback received was positive. People felt that they had been involved in any decisions made about their care, with options and consequences being fully explained. They were happy with all the care that they had received and felt that they had been well treated.

New mothers told us that staff were available, responded to any questions and provided support with their babies as necessary.

People told us that they had confidence in all the staff, who they said had the required skills to undertake their work effectively. This made them feel safe and that they could rely on the care and treatment that was provided to them

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During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

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During an inspection to make sure that the improvements required had been made

We spoke with people using the service (patients), relatives, and staff in all of the areas we visited. In total we spoke to 28 patients.

Patients told us that they felt their privacy and dignity was respected, that staff ensured curtains were closed during personal care and treatment.

We were told that patients were involved in their care and treatment. One patient told us “the doctor explained it to me”; another told us “staff come quickly when called”. The relatives of one patient told us “The consultant explained everything to us on dad’s behalf”.

Other patients spoken with confirmed that their condition, care and treatment had been discussed with them and without exception they were all satisfied with the care they had received since being admitted. One comment seemed to sum up the feeling of patients “I can’t fault the nurses here; they all do a wonderful job. It can’t be easy for them; they are so busy but seem so cheerful and always make time for you”.

Overall most patients told us they were happy with their admission process but two patients said there had been a delay in Accident and Emergency Department.

Another patient told us that they had been seen by a speech and language therapist who had provided them with advice about swallowing that they had found helpful.

We spoke with a total of 19 staff and they told us they had received training in privacy and dignity, equality and diversity, respecting patients’ choices, the Mental Capacity Act and Deprivation of Liberty Safeguards.

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During an inspection to make sure that the improvements required had been made

We visited the Accident and Emergency Department (A&E), Jevington, Seaford 3, Cuckmere, Medical Assessment Unit, and Hailsham 3 wards and spoke with patients in all these areas.

The majority of patients we spoke with told us that they felt well informed about their care and treatment, and had been involved in decision making around this.

Patients said that all staff were actively maintaining their privacy and dignity; by pulling curtains around, and lowering their voices when sensitive information was being passed over.

Patients, who were able to make decisions for themselves, told us that consent was routinely verbally sought by staff for everyday care and treatment activities.

Overall patients told us that the care they had received had been good. They also thought that nursing staff had an understanding of their needs.

The majority of patients spoken with indicated that there was enough staff on duty, and thought call bells were generally answered in a reasonably short time.

However, some patients on Seaford 3, Jevington and Cuckmere wards did raise concerns about staff responses to call bells. Two patients spoken with expressed dissatisfaction with the lack of consultation with them in respect of their treatment or preferences.

In discussion, all the patients spoken with thought that the general standard of cleanliness was good. They said that cleaning was always happening, and that staff were always washing their hands, and using the alcohol based hand gels.

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During a themed inspection looking at Dignity and Nutrition

Some of the patients spoken with and three visiting relatives told us that they were in the main satisfied with the care and treatment they received at Eastbourne District General Hospital. They said they had been treated with courtesy and respect and that their privacy and dignity had been promoted and well-protected whilst receiving personal care.

Direct quotes include “Very helpful and kind” “Always lower their voice when giving me personal care” “Pretty good, staff are well meaning, I find it very hard to sleep because it is so noisy”.

Other patients spoken with were not so positive about their experience in hospital. One comment received from a patient indicated that her experience was mixed, “Can not complain, staff kind but meal times are a nightmare for me, last week they insisted on feeding me, this week they aren’t, if I could reach my meal I could feed myself. “

The feedback about the quality, range and availability of food was mixed. Breakfast was said to be the best meal of the day, and supper was the worst. The feedback taken from the medical ward was that patients indicated that the meals were very nice and appetising at lunchtime, although the vegetables were often overcooked.

“Not bad, but I am not here just for the food” The same standard was not described as acceptable at suppertime. The patients commented on the lack of choice, pasta dishes overcooked and often unpalatable, “The supper is terrible” “I’ve put on weight, because I am eating so many biscuits and cakes”. The surgical ward patients said

“Too heavy and stodgy” “I can not eat that” “Good food, but not always the hottest”

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During a routine inspection

We spoke to people using the services and staff in each of the areas that we visited. People who use the service generally felt that they were looked after well and that staff were attentive and caring.

Comments received included, “Care is not bad” that you “get told about things if you ask, they will tell you” “Care is first class, no evidence of the horror stories you hear”.

One person felt they were receiving conflicting information from doctors, and that they were being passed between the medical and surgical teams. Another commented that they found doctors “quite helpful”.

The provision of food in the hospital was not reviewed but people spoken with offered their opinion. Two people on maternity said that the food was poor and they have been eating sandwiches since they were admitted two days ago. One person stated that they had to rely on friends and family for fruit and pasta to be brought in by them to get a balanced diet as they felt the choices available did not offer this.

Overall people stated that the level of cleanliness was very good and that the wards are swept and cleaned on a regular basis. People have seen that beds and equipment are cleaned between uses. Most people said that hand cleaning is carried out by staff in advance of any care being provided.

Comments received in respect of the cleanliness of the hospital included, “Reasonably clean, considering the number of people going through”, “Quite impressed, regularly cleaned, they clean equipment between uses and wash hands properly” “Cleanliness is very good there is a permanent cleaner every morning, they clean and wash everything”

A relative of a patient said that they felt that there was a very good standard of cleanliness and that staff were very good at washing hands and wearing aprons. Another patient said that cleanliness on the ward was pretty good but it was not particularly tidy. One person said that hand washing does not always happen.

People stated when asked that they thought there were enough staff on duty on each shift. Comments regarding staff included ‘excellent’, ‘helpful’, ‘staff did extremely well’, “plenty of staff on duty” “Yes there are enough staff, no complaints, not had to wait for anything” “The call bell is important if you have limited mobility, they’re very responsive”. One patient stated they had seen other patients who could not use the call bell waiting for staff to respond but this had not personally happened to them. One person reported that lots of bells went off at night and they had pulled the bell and waited approximately 5 minutes for staff to attend and provide pain relief.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.